Flight Shift

It’s a familiar story: after getting selected and working through thousands of hours of lectures, training, and evaluations, I was told I was ready. Yet after all that, when I heard the first code of my career, my mind went blank, my heart took off, anxiety took over and I was left scared and overwhelmed.

That was the second time in my life I felt exactly that way. The first time, I had just completed my final checkride in the F-15C with my Squadron Commander. After several years of training, I was finally a “Combat Mission Ready” F-15C pilot. That final checkride was on September 10, 2001. The next day I was prepping F-15C’s armed to the teeth with live weapons, and I was scared and overwhelmed.

As both a brand new fighter pilot and a new physician I was just barely safe, but there was a difference in how I coped with the stress. Inherent in the training of a combat pilot are cognitive tools and lessons taught to keep pilots alive and carrying out their missions under the most extreme situations. We used to say that these lessons were written in blood. As resuscitationists, we can learn from combat pilots and apply these same cognitive tools in the ED.

Imagine this: you are a combat pilot flying across the line. You are at 30,000 feet leading an 8-ship of F-15Cs (air-to-air fighters) protecting a strike package of some 30 other jets and assets. The radio calls are nonstop, your radar looks like a Christmas tree, you’re getting “spiked”, you have a minor hydraulics problem, the formation is getting sloppy, the strike package is not where it should be, and now radar control calls a new hostile group of your nose. You’ve got what pilots call a “helmet fre” – you’ve momentarily lost situational awareness because of stress and task saturation. But you know how to deal with it because of your training.

This is not unlike a nightmare scenario in the resuscitation bay. Imagine you have a crashing 55-year-old GI bleeder. The ED is packed. The nurses are having a hard time getting IV access. The patient is getting somnolent. Everyone is well intentioned but completely disorganized. You haven’t intubated someone this sick in years. Your mind is running in circles. You’re embarrassed to ask for help or reference any resources. You fixate on his O2 sats going down. There is a vacuum of leadership because you are so task-saturated you can’t co-ordinate your team. You too have a “helmet fire”. How do you deal with it? Has your training formally prepared you?

In high stress situations, the combat pilot focuses first on himself and his jet, then moves out to the team, and then the organization. A resuscitationist can do the same. Here are specific concepts from combat aviation that you can use in your EDs tomorrow:

Self: The Boldface

An aviation concept introduced on day one of pilot training is that of “The Boldface”. These are very succinct corrective procedures that address those few emergencies or tactical situations in which you have to do something right now or people will die. There’s only a few of these for each jet. In the F-15 there were maybe six. Things like engine fire, spin recovery, ejection… the “no shitters” as we called them. “The Boldface” are designed so that when you are incredibly overwhelmed, task saturated, and time is short, you can still function and survive. These procedures are absolutely committed to memory such that you know them verbatim at any given time.

We don’t really have this concept in emergency medicine. But we could since only a few emergencies really need to be treated within seconds. Pulseless VFib/ VTach comes to mind. The Boldface would read, “Shock, start CPR”. After the Boldface is completed, use your resources and checklists. Checklists liberate our minds to do “doctor things” and not get caught in the weeds. It is unconscionable that it is considered “weak” or “not cool” to use resources like this that can save lives. The hubris required to think that we as doctors don’t need backup like this is just unforgivable. Jet Jocks aren’t too cool to use them, so why are we?

Self: Crosscheck

The basic aviation concept here is to never fixate on any one instrument or parameter. In a tactical situation, if you fixate on any one instrument – the radar, your tactical display, your “spike status”, the radios – you will miss critical information and someone will die. Likewise, in a resuscitation, we cannot fixate on any one instrument or vital sign. We’ve all seen the situation where everyone is hypnotized by a positive FAST while the patient is bleeding out, or there is a bad open tib-fib fracture that everyone zeros in on while the patient is apneic.

Translating this aviation concept to medicine, we need to take a position of leadership, likely at the foot of the bed, and start our medical crosscheck. Mine revolves around the patient and goes something like patient – O2 sats – patient – nursing – patient – BP – patient – medics – patient – ultrasound, etc.. This crosscheck will help us see the global picture and set appropriate priorities.

Self: Task Prioritization

A core aviation mantra is “Aviate–Navigate –Communicate”. This is always the order you do things in the jet. I have studied multiple jet mishaps where this was the root cause of an airplane turning into a smoking hole. In fact, one time while flying the F-15C, I was so task saturated by looking at my radar and listening to the tactical comm that I found myself at 90 degrees of bank, 30 degrees nose low, and 550 knots at 1000 feet above the ocean which looked just like the sky. I was navigating and communicating, but I wasn’t aviating. I had 5-10 seconds to live when the Hand of God lifted my eyes out of that cockpit and got me aviating again.

Now, I think this concept can especially help our residents with attention prioritization in a resuscitation. The medical spin on this concept would be “Resuscitate (ABCs)–Differentiate–Communicate”.

Resuscitate (ABCs): Accomplish the boldface and secure the most immediate ABCs Differentiate: Figure out where we’re going via our differential, then bring order to chaos

Communicate: With our team as the team leader

Team: Communication

Efficiency in communication during a dogfight is imperative. If a bandit rolled up behind my wingman I would call, “EAGLE 2, BRAKE RIGHT, FLARE! Bandit, your 6 o’clock high 1 mile”. Communication follows a hierarchy. It is directive, then descriptive, then informative.

Now, how can we use this in a resuscitation? We’ve all seen resuscitations go horribly because the lead physician doesn’t step up. There is a vacuum of leadership and communication. That vacuum can only be filled by us. It is why we trained and why we are there. It is what the team needs and wants. Our leadership brings order to chaos.

So we must be directive, descriptive and informative. Directive: Talk to someone specifically and give directions. “Resident Smith, place a central line.” Descriptive: “in the right femoral vein.” Informative: “we’re having problems getting IV access and the patient is bleeding out.”

In one sentence, a specific team member knows exactly what is expected of them and why. Clear unambiguous communication is your leadership in action.

Team: Briefing

The idea with a pre-flight briefing is to plan your sortie. The Flight Lead establishes a singular mission, defines roles, and sets the tone. The saying was that if it was a good briefing, it would be a good mission. These briefings typically took about an hour.

Now, an hour pre-brief is clearly not possibly in a resuscitation. But this concept can easily be applied to us. A 20-second briefing, even if the patient is already in front of us, is wildly valuable. This is as simple as stating what is known about the patient. This does a couple things: it establishes that someone is leading the resuscitation, it gets everyone on the same page, and it starts 2-way communication with your team as they add info that you don’t know.

We’ll discuss the debrief at another time, but the bottom line is that “learning and team building happens in the debrief.”

Organization: Read Files

This is probably the easiest concept, but one that I have yet to see in any ED. In the flying world there are many moving parts with changes occurring hourly. Some examples are: a local taxiway is out, there are new ordinance arming procedures or the departure procedure has changed. All of these items are very important and impact your sortie. The Pre-Flight Read Files consolidate this information in a simple, easily referenced binder. Pilots are simply not allowed to fly until they’ve read and signed of the current Read Files. This rarely takes more than a few minutes to accomplish. Simple.

Now, how many times are you on shift, trying to do your job, and after a delay you randomly find out that there’s a new procedure for admitting to the Peds ICU, or the hospital is out of Propofol, or Psych now needs LFTs, D-dimers, and head CTs on every admission?

A Pre-Shift Read File in one centralized binder that takes no more than a minute to read before every shift solves this problem. It standardizes procedures, increases global situational awareness, and sets us up for success on our shift. Email is not acceptable, nor are messy bulletin boards from the 1980s. This is a simple solution to keeping us current on what’s going on in the ED and the hospital.

So let’s apply these concepts to the 55-year-old GI Bleeder from earlier…

“The Boldface” dictates immediate actions for the most critical emergencies:

You are the resuscitationist, you bring order to chaos, you quickly assess this patient and note that right now there is no Boldface to accomplish, you take a position of leadership at the foot of the bed.

“Resuscitate (ABCs) – Differentiate – Communicate” mantra directs focus and prioritization. You need to get IV access, secure the airway, and start blood. At the top of your differential are esophageal varices and peptic ulcers.

“Briefing” gives the team a vector. You give a 20-second briefing to organize your team, spell out your immediate thought process, and get everyone on the same page. “OK, we have a sick 55-year-old GI bleeder who is pale, hypotensive, tachycardic and becoming somnolent. Lets plan on intubating him and starting emergency release blood.” Your medics and nurses start feeding you more information.

“Medic Smith, bring the airway cart in here, we will be intubating to protect his airway.”

“Read Files” give current need-to-know information. You want to start the massive transfusion protocol and recall from today’s Read File exactly how to initiate it.

Well done! You are the resuscitationist. You just brought order to chaos; you’ve tamed your own epinephrine surge and you’ve given your team leadership and confidence. You have a vector, and you are now ready for the rest of this challenge.

Now, I understand there may be skeptics. Also, I recognize that “aviation concepts in medicine” is not a panacea, and won’t work for every situation. However, over the years I’ve truly come to appreciate the wisdom embodied in my training as a fighter pilot and I’ve incorporated that into my practice as an EP. I’m convinced these concepts have saved lives in my ED, and hopefully they can help you in yours.

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